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Lama Skieker: Severe Thrombocytopenia Demands Systematic Diagnosis Before Labeling ITP

Lama Skieker/LinkedIn

Jul 5, 2026, 10:53

Lama Skieker: Severe Thrombocytopenia Demands Systematic Diagnosis Before Labeling ITP

Lama Skieker, Clinical Pathologist at Bader Alsama Barka, shared a post on LinkedIn:

“A recent hematology case reminded me how important it is not to label every case of severe thrombocytopenia as immune thrombocytopenia (ITP) too early.

A patient presented to the Emergency Department with:

Fever for more than one week, Myalgia,Elevated CRP
Severe thrombocytopenia (~33 × 10⁹/L)

Testing for dengue and malaria was negative.

The peripheral blood smear confirmed true thrombocytopenia with normal platelet morphology and distribution, and a repeat sample confirmed the CBC result.

Despite transfusion of multiple platelet units, there was no significant platelet count increment.

This raises an important diagnostic question:

Are we dealing with immune-mediated platelet destruction, ongoing platelet consumption, platelet transfusion refractoriness, or an underlying infectious or drug-related process?

Before diagnosing primary ITP, it is essential to maintain a broad differential diagnosis.

Conditions that should be considered include:

Immune thrombocytopenia (ITP): A diagnosis of exclusion after secondary causes such as viral infections, autoimmune disease, medications, hepatitis, HIV, and H. pylori have been evaluated.
Thrombotic thrombocytopenic purpura (TTP) and other thrombotic microangiopathies: Consider if thrombocytopenia is accompanied by hemolysis, schistocytes, elevated LDH, renal dysfunction, or neurological findings.
Hemolytic uremic syndrome (HUS): Particularly when thrombocytopenia is associated with microangiopathic hemolytic anemia and acute kidney injury.
HELLP syndrome: An essential consideration in pregnant or postpartum patients with hemolysis, elevated liver enzymes, and thrombocytopenia.
Heparin-induced thrombocytopenia (HIT): Evaluate recent heparin exposure, timing of platelet decline, thrombosis, and the 4Ts score before laboratory testing.
Drug-induced immune thrombocytopenia: Always perform a careful medication review. Antibiotics, heparin, quinine-containing products, antiepileptics, NSAIDs, and several other medications may cause abrupt severe thrombocytopenia.

A systematic evaluation may include serial CBCs, repeat peripheral smear, coagulation profile, fibrinogen, D-dimer, LDH, bilirubin, haptoglobin, reticulocyte count, direct antiglobulin test (DAT), renal and liver function tests, blood and urine cultures, viral screening, autoimmune testing, medication review, and ADAMTS13 testing when TTP is suspected.

Take-home message:

evere thrombocytopenia with poor platelet transfusion response should prompt a systematic search for immune destruction, platelet consumption, infection, thrombotic microangiopathy, and drug-related causes rather than relying on platelet transfusion alone.

Every low platelet count tells a story. Our role is to identify the underlying mechanism before assigning the diagnosis.”

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